Provider Demographics
NPI:1598701591
Name:BLUE CREEK MEDICINE PC
Entity Type:Organization
Organization Name:BLUE CREEK MEDICINE PC
Other - Org Name:BLUE CREEK FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIT
Authorized Official - Middle Name:K
Authorized Official - Last Name:BREKHUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-674-2273
Mailing Address - Street 1:PO BOX 1926
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80437-1926
Mailing Address - Country:US
Mailing Address - Phone:303-674-2273
Mailing Address - Fax:303-670-2160
Practice Address - Street 1:1520 EVERGREEN PKWY
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7848
Practice Address - Country:US
Practice Address - Phone:303-674-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COBL661575OtherBLUE SHIELD
COCK5669OtherRR MEDICARE
CO45959234Medicaid
COBL661575OtherBLUE SHIELD
COC494818Medicare PIN